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Schwab RJ, Lin TC, Wiemken A, Dedhia RC, Wehrli FW, Keenan BT. State-Dependent Biomechanical Behavior of Oropharyngeal Structures in Apneic and Control Subjects: A Proof-of-Concept Study. Ann Am Thorac Soc 2024; 21:949-960. [PMID: 38507612 PMCID: PMC11160136 DOI: 10.1513/annalsats.202309-847oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 03/20/2024] [Indexed: 03/22/2024] Open
Abstract
Rationale: Apneic individuals have reduced airway caliber during sleep. The biomechanical changes in upper airway anatomy contributing to this airway narrowing are largely unknown. Objectives: We sought to investigate the state-dependent (wake vs. sleep) biomechanical behavior of the upper airway soft-tissue and craniofacial structures. Methods: Upper airway magnetic resonance imaging was performed in 15 sleep-deprived control subjects (apnea-hypopnea index, <5; 0.3 ± 0.5 events per hour) and 12 sleep-deprived apneic subjects (apnea-hypopnea index, ⩾5; 35.2 ± 18.1 events per hour) during wake and sleep and analyzed for airway measures and soft-tissue/mandibular movement. Results: In the retropalatal region, control subjects showed sleep-dependent reductions (P ⩽ 0.037) in average cross-sectional airway area (CSA), minimum CSA, and anteroposterior and lateral dimensions. Apneic subjects showed sleep-dependent reductions (P ⩽ 0.002) in average CSA, minimum CSA, and anteroposterior and lateral dimensions. In the retroglossal region, control subjects had no sleep-dependent airway reductions. However, apneic subjects had sleep-dependent reductions in minimal CSA (P = 0.001) and lateral dimensions (P = 0.014). Control subjects only showed sleep-dependent posterior movement of the anterior-inferior tongue octant (P = 0.039), whereas apneic subjects showed posterior movement of the soft palate (P = 0.006) and all tongue octants (P ⩽ 0.012). Sleep-dependent medial movement of the lateral walls was seen at the retropalatal minimum level (P = 0.013) in control subjects and at the retropalatal and retroglossal minimum levels (P ⩽ 0.017) in apneic subjects. There was posterior movement of the mandible in apneic subjects (P ⩽ 0.017). Conclusions: During sleep, control and apneic subjects showed reductions in retropalatal airway caliber, but only the apneic subjects showed retroglossal airway narrowing. Reductions in anteroposterior and lateral airway dimensions were primarily due to posterior soft palate, tongue and mandibular movement and to medial lateral wall movement. These data provide important initial insights into obstructive sleep apnea pathogenesis.
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Affiliation(s)
| | - Theodore C. Lin
- Division of Sleep Medicine, Department of Medicine
- Department of Otorhinolaryngology – Head and Neck Surgery, Temple University, Philadelphia, Pennsylvania
| | | | - Raj C. Dedhia
- Division of Sleep Medicine, Department of Medicine
- Department of Otorhinolaryngology – Head and Neck Surgery, and
| | - Felix W. Wehrli
- Laboratory for Structural, Physiologic, and Functional Imaging, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania; and
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He Y, Liu WT, Lin S, Li Z, Qiu H, Yim SHL, Chuang HC, Ho KF. The joint association of ambient air pollution and different sleep posture with mild obstructive sleep apnea: A study conducted at Taipei Sleep Center. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 903:166531. [PMID: 37633386 DOI: 10.1016/j.scitotenv.2023.166531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/02/2023] [Accepted: 08/22/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Growing evidence suggests the detrimental impact of supine position and air pollution on obstructive sleep apnea (OSA), as well as the potential benefits of nonsupine positions. However, their interaction effects on OSA remain unclear. OBJECTIVES To evaluate the interaction effects of air pollution (NO2/PM2.5) and sleep position on OSA on additive and multiplicative scales. METHODS This study included 3330 individuals. Personal exposure to air pollution was assessed using a spatiotemporal model. OSA was diagnosed through polysomnography. The associations of supine and nonsupine positions and air pollutants with mild-OSA and their interaction effects on mild-OSA. were explored through generalized logistic regression. RESULTS Supine position and high NO2 level independently increased the risk of mild-OSA, while PM2.5 was not associated with mild-OSA. Significant interactions were observed between supine position and NO2 at different lag periods (0-7 days, 0-1 year, and 0-2 years) (P = 0.042, 0.013, and 0.010, respectively). The relative excess risks due to interactions on the additive scale for 1-week, 1-year, and 2-year NO2 exposure and supine position were 0.63 (95 % CI: 0.10-1.16), 0.56 (95 % CI: 0.13-0.99), and 0.64 (95 % CI: 0.18-1.10); the corresponding odds ratios for interactions on the multiplicative scale were 1.45 (95 % CI: 1.01-2.07), 1.55 (95 % CI: 1.09-2.22), and 1.60 (95 % CI: 1.12-2.28). The positive interactions persisted in men and participants with obesity. No interaction was observed between nonsupine position and NO2 levels; nevertheless, significant interactions were noted on both the negative additive and multiplicative scales in men. CONCLUSION Prolonged supine sleep significantly increased the risk of mild-OSA, particularly in men and individuals with obesity. Although the benefits of nonsupine position are considerably less than the risks of NO2 exposure, avoiding prolonged supine sleep may reduce the risk of mild-OSA caused by high levels of NO2 in men.
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Affiliation(s)
- Yansu He
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, HKSAR, China
| | - Wen-Te Liu
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shangyang Lin
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Zhiyuan Li
- Institute of Environment, Energy and Sustainability, The Chinese University of Hong Kong, HKSAR, China
| | - Hong Qiu
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, HKSAR, China
| | - Steve Hung Lam Yim
- The Asian School of the Environment, Nanyang Technological University, Singapore
| | - Hsiao-Chi Chuang
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Cell Physiology and Molecular Image Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Kin Fai Ho
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, HKSAR, China; Institute of Environment, Energy and Sustainability, The Chinese University of Hong Kong, HKSAR, China.
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Johal A, Hamoda MM, Almeida FR, Marklund M, Tallamraju H. The role of oral appliance therapy in obstructive sleep apnoea. Eur Respir Rev 2023; 32:220257. [PMID: 37343962 DOI: 10.1183/16000617.0257-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/12/2023] [Indexed: 06/23/2023] Open
Abstract
There is now widespread recognition within the world of sleep medicine of the increasing importance of dental sleep medicine and, in particular, the role of oral appliance therapy (OAT) in the management of adults with obstructive sleep apnoea (OSA). For the purpose of this review, the term OAT refers to a custom-made intra-oral appliance, which acts to posture the mandible in a forward and downward direction, away from its natural resting position. Whilst nasally applied continuous positive airway pressure remains the "gold standard" in nonsurgical OSA management, OAT remains the recognised alternative treatment.This review of OAT aims to provide an evidence-based update on our current understanding of their mode of action, exploring the potential anatomical and physiological impact of their use in preventing collapse of the upper airway; the current clinical practice guidelines, including the recently published National Institute of Clinical Excellence 2021 guidance, in conjunction with the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine; optimal design features, comparing the role of custom-made versus noncustom OAT devices and the importance of titration in achieving a dose-dependent effect; patient predictors, preference and adherence to OAT; its impact on a range of both patient- and clinician-centred health outcomes, with a comparison with CPAP; the limitations and side-effects of providing OAT; and, finally, a look at future considerations to help optimise the delivery and outcomes of OAT.
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Affiliation(s)
- Ama Johal
- Oral Bioengineering, Institute of Dentistry, Queen Mary, University of London, London, UK
| | - Mona M Hamoda
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Fernanda R Almeida
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Marie Marklund
- Department of Otontology, Medical Faculty, Umea University, Umea, Sweden
| | - Harishri Tallamraju
- Oral Bioengineering, Institute of Dentistry, Queen Mary, University of London, London, UK
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Prasad S, Arunachalam S, Boillat T, Ghoneima A, Gandedkar N, Diar-Bakirly S. Wearable Orofacial Technology and Orthodontics. Dent J (Basel) 2023; 11:24. [PMID: 36661561 PMCID: PMC9858298 DOI: 10.3390/dj11010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/19/2022] [Accepted: 12/30/2022] [Indexed: 01/12/2023] Open
Abstract
Wearable technology to augment traditional approaches are increasingly being added to the arsenals of treatment providers. Wearable technology generally refers to electronic systems, devices, or sensors that are usually worn on or are in close proximity to the human body. Wearables may be stand-alone or integrated into materials that are worn on the body. What sets medical wearables apart from other systems is their ability to collect, store, and relay information regarding an individual's current body status to other devices operating on compatible networks in naturalistic settings. The last decade has witnessed a steady increase in the use of wearables specific to the orofacial region. Applications range from supplementing diagnosis, tracking treatment progress, monitoring patient compliance, and better understanding the jaw's functional and parafunctional activities. Orofacial wearable devices may be unimodal or incorporate multiple sensing modalities. The objective data collected continuously, in real time, in naturalistic settings using these orofacial wearables provide opportunities to formulate accurate and personalized treatment strategies. In the not-too-distant future, it is anticipated that information about an individual's current oral health status may provide patient-centric personalized care to prevent, diagnose, and treat oral diseases, with wearables playing a key role. In this review, we examine the progress achieved, summarize applications of orthodontic relevance and examine the future potential of orofacial wearables.
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Affiliation(s)
- Sabarinath Prasad
- Department of Orthodontics, Hamdan Bin Mohammed College of Dental Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai 50505, United Arab Emirates
| | - Sivakumar Arunachalam
- Orthodontics and Dentofacial Orthopedics, School of Dentistry, International Medical University, Kuala Lumpur 57000, Malaysia
| | - Thomas Boillat
- Design Lab, College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai 50505, United Arab Emirates
| | - Ahmed Ghoneima
- Department of Orthodontics, Hamdan Bin Mohammed College of Dental Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai 50505, United Arab Emirates
| | - Narayan Gandedkar
- Discipline of Orthodontics & Paediatric Dentistry, School of Dentistry, University of Sydney, Sydney, NSW 2006, Australia
| | - Samira Diar-Bakirly
- Department of Orthodontics, Hamdan Bin Mohammed College of Dental Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai 50505, United Arab Emirates
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Sleep-related breathing disorders in young orthodontic patients. Am J Orthod Dentofacial Orthop 2023; 163:95-101. [PMID: 36184392 DOI: 10.1016/j.ajodo.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 09/01/2021] [Accepted: 09/01/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION This study aimed to find out the frequency of sleep-related breathing disorders (SRBD) in young orthodontic patients in Israel. SRBD is characterized by prolonged upper airway obstruction during sleep. METHODS The study group consisted of 309 children aged 6-17 years who attended the Orthodontic Clinic at Hadassah Medical Center. Parents were asked to complete a translated validated Pediatric Sleep Questionnaire. RESULTS Of the examined children, 10% were at high risk for SRBD. Boys were at higher risk for SRBD and were at high risk at a younger age than girls. Girls had a low risk of SRBD after adenotonsillectomy, whereas 50% of the boys that underwent adenotonsillectomy were at high risk for SRBD. CONCLUSIONS Our findings propose that 10% of the children aged 6-17 years, who were seeking orthodontic consultation at our medical center, were at high risk for SRBD. Boys were significantly at a higher risk for SRBD than girls and were at high risk at a younger age. It is important to screen young orthodontic patients for SRBD and to refer high-risk patients to their physicians for further evaluation and treatment.
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Jaffuel D, Borel JC. If Oral Breathing Does Not Determine Mask Choice for Continuous Positive Airway Pressure Delivery, What Does? Am J Respir Crit Care Med 2022; 205:1363-1364. [PMID: 35363121 PMCID: PMC9873112 DOI: 10.1164/rccm.202112-2823le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Dany Jaffuel
- Centre Hospitalier Universitaire de MontpellierMontpellier, France
| | - Jean Christian Borel
- Grenoble Alps UniversityGrenoble, France,Association Grenobloise des Insuffisants Respiratoires à DomMeylan, France,Corresponding author (e-mail: )
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Sanz PM, Reyes MG, Torras AB, Castillo JAC, Vich MOL. Craniofacial morphology/phenotypes influence on mandibular range of movement in the design of a mandibular advancement device. BMC Oral Health 2021; 21:19. [PMID: 33413283 PMCID: PMC7791719 DOI: 10.1186/s12903-020-01369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 12/16/2020] [Indexed: 12/02/2022] Open
Abstract
Background The mandibular opening path movements have different directions according to the craniofacial morphology of the patient but always downward and backward, therefore increasing the collapse of the upper airway. The aim of this work is to determine if there is a relationship between the craniofacial morphology and the mandibular movement to help understand the impact on the mandibular position. Methods 52 students with full permanent dentition aged 19 to 23 years (mean 21.3 SD 1.7; 29 females and 23 males), participated in the study. Each subject had a lateral cephalometric radiograph taken. The opening angle was determined for two levels of vertical openings at 5 and 10 mm. Results The opening angle showed a greater variability between subjects ranging from 63.15 to 77.08 for 5 mm angle and from for 61.65 to 75.72 for the 10 mm angle. Differences of facial phenotypes was evident when comparing the individual dissoccluding angle of the low angle horizontal pattern and high angle vertical pattern. Conclusions The opening angle is related to craniofacial morphology with higher vertical anterior and shorter anteroposterior faces having a more horizontal path of mandibular movement than shorter vertical anterior and longer anteroposterior subjects who have a more vertical path.
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Affiliation(s)
- P Mayoral Sanz
- Master Program Dental Sleep Medicine, Catholic University of Murcia UCAM, Conde de Peñalver 61, 28006, Madrid, Spain
| | - M Garcia Reyes
- Faculty of Engineering, University of Malaga, Flauta Mágica 22, 29006, Málaga, Spain
| | - A Bataller Torras
- Faculty of Engineering, University of Malaga, Flauta Mágica 22, 29006, Málaga, Spain
| | - J A Cabrera Castillo
- Faculty of Engineering, University of Malaga, Flauta Mágica 22, 29006, Málaga, Spain
| | - M O Lagravère Vich
- Faculty of Medicine and Dentistry, School of Dentistry, University of Alberta ECHA, 5-524, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada.
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The key role of the mandible in modulating airflow amplitude during sleep. Respir Physiol Neurobiol 2020; 279:103447. [DOI: 10.1016/j.resp.2020.103447] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 11/20/2022]
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García M, Cabrera JA, Bataller A, Vila J, Mayoral P. Mandibular movement analisys by means of a kinematic model applied to the design of oral appliances for the treatment of obstructive sleep apnea. Sleep Med 2020; 73:29-37. [PMID: 32769030 DOI: 10.1016/j.sleep.2020.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/16/2020] [Accepted: 04/19/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mandibular advancement devices (MADs) are one of the treatment options used for the obstructive sleep apnea syndrome (OSAS). At present, MADs are designed with standard titration systems, without considering each patient's anatomical characteristics of the temporomandibular joint and mandible shape. The main objective of this study is to evaluate if a variability in mandibular morphology will influence the displacement of the jaw with a MAD. Such knowledge will be of help to find optimal mandibular positions with MAD even when opening the mouth. METHODS By using a mandibular movement model, the movement patterns of different points on the chin have been analyzed. The influence of different skeletal mandibular shapes on these movements have also been studied. The results show differences in the movement patterns of the lower front teeth depending on its distance to the center of the condyle, with a more horizontal direction in those in which there is a greater distance. RESULTS Variations in mandibular morphology imply differences in movement patterns of the analyzed points of the mandible. Consequently, MADs should be designed according to each patient's anatomy to avoid mandibular retrusion in those areas that may narrow the upper airways. CONCLUSIONS This study may help to understand why not all patients move their lower jaws forwards equally with the same degree of mandibular protrusion measured in relation to the teeth. These results might also partially explain why airway obstruction is more severe in certain untreated sleep apnea subjects than in others when opening their mouth during sleep.
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Affiliation(s)
- Marcos García
- Department of Mechanical Engineering, University of Málaga, Spain
| | - Juan A Cabrera
- Department of Mechanical Engineering, University of Málaga, Spain.
| | - Alex Bataller
- Department of Mechanical Engineering, University of Málaga, Spain
| | - Javier Vila
- Otorhinolaryngology, Hospital Vall d Hebron, Barcelona, Spain
| | - Pedro Mayoral
- Master Program of Dental Sleep Medicine, Catholic University of Murcia, Spain
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Nasopharyngeal Tube Effects on Breathing during Sedation for Dental Procedures: A Randomized Controlled Trial. Anesthesiology 2020; 130:946-957. [PMID: 30870163 DOI: 10.1097/aln.0000000000002661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC Dental procedures under sedation can cause hypoxic events and even death. However, the mechanism of such hypoxic events is not well understood. WHAT THIS ARTICLE TELLS US THAT IS NEW Apnea and hypopnea occur frequently during dental procedures under sedation. The majority of the events are not detectable with pulse oximetry. Insertion of a nasal tube with small diameter does not reduce the incidence of apnea/hypopnea. BACKGROUND Intravenous sedation is effective in patients undergoing dental procedures, but fatal hypoxemic events have been documented. It was hypothesized that abnormal breathing events occur frequently and are underdetected by pulse oximetry during sedation for dental procedures (primary hypothesis) and that insertion of a small-diameter nasopharyngeal tube reduces the frequency of the abnormal breathing events (secondary hypothesis). METHODS In this nonblinded randomized control study, frequency of abnormal breathing episodes per hour (abnormal breathing index) of the patients under sedation for dental procedures was determined and used as a primary outcome to test the hypotheses. Abnormal breathing indexes were measured by a portable sleep monitor. Of the 46 participants, 43 were randomly allocated to the control group (n = 23, no nasopharyngeal tube) and the nasopharyngeal tube group (n = 20). RESULTS In the control group, nondesaturated abnormal breathing index was higher than the desaturated abnormal breathing index (35.2 [20.6, 48.0] vs. 7.2 [4.1, 18.5] h, difference: 25.1 [95% CI, 13.8 to 36.4], P < 0.001). The obstructive abnormal breathing index was greater than central abnormal breathing index (P < 0.001), and half of abnormal breathing indexes were followed by irregular breathing. Despite the obstructive nature of abnormal breathing, the nasopharyngeal tube did not significantly reduce the abnormal breathing index (48.0 [33.8, 64.4] h vs. 50.5 [36.4, 63.9] h, difference: -2.0 [95% CI, -15.2 to 11.2], P = 0.846), not supporting the secondary hypothesis. CONCLUSIONS Patients under sedation for dental procedure frequently encounter obstructive apnea/hypopnea events. The majority of the obstructive apnea/hypopnea events were not detectable by pulse oximetry. The effectiveness of a small-diameter nasopharyngeal tube to mitigate the events is limited.
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Leotard A, Lebret M, Prigent H, Arnol N, Pépin JL, Hartley S, Lofaso F, Borel JC. Facteurs associés au masque de ventilation non invasive nocturne chez les patients neuromusculaires adultes. Rev Mal Respir 2020; 37:99-104. [DOI: 10.1016/j.rmr.2019.11.646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/26/2019] [Indexed: 11/29/2022]
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A Device Improves Signs and Symptoms of TMD. Pain Res Manag 2019; 2019:5646143. [PMID: 31198477 PMCID: PMC6526566 DOI: 10.1155/2019/5646143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/13/2019] [Accepted: 04/07/2019] [Indexed: 12/18/2022]
Abstract
Background Temporomandibular joint dysfunction (TMD) therapy remains an open challenge for modern dentistry. Herein, we propose a new neuromuscular lingual device able to reduce signs and symptoms of TMD in female patients with chronic orofacial pain. Methods 50 females with myofascial TMD according to RDC/TMD were randomly assigned to study (n = 25) and control groups (n = 25). At T0, both groups received sEMG/KNG and pain evaluation by the VAS scale. The study group received the ELIBA device (lingual elevator by Balercia) constructed under ULF-TENS (ultra-low-frequency transcoutaneous electrical nervous stimulation). Subjects were instructed to use ELIBA at least for 16 h/day. After 6 months (T1), both groups underwent to sEMG/KNG and VAS revaluation. Results T1 study group compared to controls showed a significant reduction in total (p < 0.0001) and mean (p < 0.0001) sEMG values, as well as a significant increase in both maximum vertical mouth opening (p=0.003) and maximum velocity in mouth opening (p=0.003) and closing (p < 0.0001). Interestingly, a significant reduction in pain measured by VAS (p < 0.0001) was reported. Conclusions After 6 months, the ELIBA device is able to significantly reduce TMD-associated myogenous pain and to promote the enhancement of sEMG/KNG values. Practical Implications ELIBA can be considered as a new device, potentially useful for head-neck pain relief in patients suffering from chronic TMD. In addition, its use promotes a muscles relaxation inducing freeway space increase. This characteristic makes it particularly useful for rehabilitation of patients with not enough space for construction of conventional orthotics or neuromuscular bites.
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Lebret M, Arnol N, Martinot JB, Lambert L, Tamisier R, Pepin JL, Borel JC. Determinants of Unintentional Leaks During CPAP Treatment in OSA. Chest 2018; 153:834-842. [DOI: 10.1016/j.chest.2017.08.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/22/2017] [Accepted: 08/01/2017] [Indexed: 11/26/2022] Open
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Martinot JB, Le-Dong NN, Cuthbert V, Denison S, Silkoff PE, Guénard H, Gozal D, Pepin JL, Borel JC. Mandibular Movements As Accurate Reporters of Respiratory Effort during Sleep: Validation against Diaphragmatic Electromyography. Front Neurol 2017; 8:353. [PMID: 28785240 PMCID: PMC5519525 DOI: 10.3389/fneur.2017.00353] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/05/2017] [Indexed: 11/29/2022] Open
Abstract
Context Mandibular movements (MM) are considered as reliable reporters of respiratory effort (RE) during sleep and sleep disordered breathing (SDB), but MM accuracy has never been validated against the gold standard diaphragmatic electromyography (EMG-d). Objectives To assess the degree of agreement between MM and EMG-d signals during different sleep stages and abnormal respiratory events. Methods Twenty-five consecutive adult patients with SDB were studied by polysomnography (PSG) that also included multipair esophageal diaphragm electromyography and a magnetometer to record MM. EMG-d activity (microvolt) and MM (millimeter) amplitudes were extracted by envelope processing. Agreement between signals amplitudes was evaluated by mixed linear regression and cross-correlation function and in segments of PSG including event-free and SDB periods. Results The average total sleep time was 370 ± 18 min and the apnea hypopnea index was 24.8 ± 5.2 events/h. MM and EMG-d amplitudes were significantly cross-correlated: median r (95% CI): 0.67 (0.23–0.96). A mixed linear model showed that for each 10 µV of increase in EMG-d activity, MM amplitude increased by 0.28 mm. The variations in MM amplitudes (median range: 0.11–0.84 mm) between normal breathing, respiratory effort-related arousal, obstructive, mixed, and central apnea periods closely corresponded to those observed with EMG-d activity (median range: 2.11–8.23 µV). Conclusion MM amplitudes change proportionally to diaphragmatic EMG activity and accurately identify variations of RE during normal sleep and SDB.
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Affiliation(s)
| | | | | | | | | | | | - David Gozal
- University of Chicago, Chicago, IL, United States
| | - Jean-Louis Pepin
- CHU de Grenoble, Laboratoire EFCR, Pôle Thorax et Vaisseaux, Grenoble, France.,University Grenoble Alps, HP2 INSERM U1042, Grenoble, France
| | - Jean-Christian Borel
- University Grenoble Alps, HP2 INSERM U1042, Grenoble, France.,AGIR à dom. Association, Meylan, France
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Choosing the right interface for positive airway pressure therapy in patients with obstructive sleep apnea. Sleep Breath 2017; 21:569-575. [DOI: 10.1007/s11325-017-1490-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/08/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
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Gray EL, Barnes DJ. Beyond the thermistor: Novel technology for the ambulatory diagnosis of obstructive sleep apnoea. Respirology 2017; 22:418-419. [DOI: 10.1111/resp.13004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/19/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Emma L. Gray
- Department of Respiratory and Sleep Medicine; Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - David J. Barnes
- Department of Respiratory and Sleep Medicine; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- Department of Medicine; University of Sydney; Sydney New South Wales Australia
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Chakar B, Senny F, Poirrier AL, Cambron L, Fanielle J, Poirrier R. Validation of midsagittal jaw movements to measure sleep in healthy adults by comparison with actigraphy and polysomnography. ACTA ACUST UNITED AC 2017; 10:122-127. [PMID: 29410741 PMCID: PMC5699855 DOI: 10.5935/1984-0063.20170021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE In a device based on midsagittal jaw movements analysis, we assessed a
sleep-wake automatic detector as an objective method to measure sleep in
healthy adults by comparison with wrist actigraphy against polysomnography
(PSG). METHODS Simultaneous and synchronized in-lab PSG, wrist actigraphy and jaw movements
were carried out in 38 healthy participants. Epoch by epoch analysis was
realized to assess the ability to sleep-wake distinction. Sleep parameters
as measured by the three devices were compared. This included three
regularly reported parameters: total sleep time, sleep onset latency, and
wake after sleep onset. Also, two supplementary parameters, wake during
sleep period and latency time, were added to measure quiet wakefulness
state. RESULTS The jaw movements showed sensitivity level equal to actigraphy 96% and
higher specificity level (64% and 48% respectively). The level of agreement
between the two devices was high (87%). The analysis of their disagreement
by discrepant resolution analysis used PSG as resolver revealed that jaw
movements was right (58.9%) more often than actigraphy (41%). In sleep
parameters comparison, the coefficient correlation of jaw movements was
higher than actigraphy in all parameters. Moreover, its ability to distinct
sleep-wake state allowed for a more effective estimation of the parameters
that measured the quiet wakefulness state. CONCLUSIONS Midsagittal jaw movements analysis is a reliable method to measure sleep. In
healthy adults, this device proved to be superior to actigraphy in terms of
estimation of all sleep parameters and distinction of sleep-wake status.
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Affiliation(s)
- Bassam Chakar
- University Hospital of Liege, Sleep Center - Department of Neurology - Liège - Liège - Belgium
| | - Frédéric Senny
- High School HELMo-Gramme, Electronic and Informatic Unit - Liège - Liège - Belgium
| | - Anne-Lise Poirrier
- University Hospital of Liege, Rhinology and Facial Plastic Surgery - Liège - Liège - Belgium
| | - Laurent Cambron
- University Hospital of Liege, Sleep Center - Department of Neurology - Liège - Liège - Belgium
| | - Julien Fanielle
- University Hospital of Liege, Sleep Center - Department of Neurology - Liège - Liège - Belgium
| | - Robert Poirrier
- University Hospital of Liege, Sleep Center - Department of Neurology - Liège - Liège - Belgium
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Lebret M, Martinot JB, Arnol N, Zerillo D, Tamisier R, Pepin JL, Borel JC. Factors Contributing to Unintentional Leak During CPAP Treatment: A Systematic Review. Chest 2016; 151:707-719. [PMID: 27986462 DOI: 10.1016/j.chest.2016.11.049] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/09/2016] [Accepted: 11/29/2016] [Indexed: 12/30/2022] Open
Abstract
CPAP is the first-line treatment for moderate to severe OSA syndrome. Up to 25% of patients with OSA syndrome discontinue CPAP treatment due to side effects. Unintentional leakage and its associated annoying consequences are the most frequently reported adverse effects of CPAP. Successive technological improvements have not succeeded in addressing this issue. A systematic review was conducted (1) to assess the impact of different technological advances on unintentional leaks and (2) to determine if any patient characteristics have already been identified as determinants of unintentional leakage. No CPAP modality was superior to another in reducing unintentional leaks and, surprisingly, oronasal masks were associated with higher unintentional leaks. Nasal obstruction, older age, higher BMI, central fat distribution, and male sex might be associated with an increased risk of unintentional leakage. Such leaks remain an important problem. Further studies are needed to improve the understanding of underlying clinical factors so that patients at risk of unintentional leaks may be identified and individualized solutions applied.
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Affiliation(s)
- Marius Lebret
- Department of Research and Development, Association AGIR à dom, HP2 Laboratory, INSERM U 1042, Meylan, France.
| | | | - Nathalie Arnol
- Department of Research and Development, Association AGIR à dom, HP2 Laboratory, INSERM U 1042, Meylan, France
| | - Daniel Zerillo
- Department of Research and Development, Association AGIR à dom, HP2 Laboratory, INSERM U 1042, Meylan, France
| | - Renaud Tamisier
- Thorax and Vessels Division, Sleep Laboratory, Grenoble Alpes University, HP2 Laboratory, INSERM U 1042, Grenoble, France
| | - Jean-Louis Pepin
- Thorax and Vessels Division, Sleep Laboratory, Grenoble Alpes University, HP2 Laboratory, INSERM U 1042, Grenoble, France
| | - Jean-Christian Borel
- Department of Research and Development, Association AGIR à dom, HP2 Laboratory, INSERM U 1042, Meylan, France; Thorax and Vessels Division, Sleep Laboratory, Grenoble Alpes University, HP2 Laboratory, INSERM U 1042, Grenoble, France
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Lebret M, Arnol N, Contal O, Martinot JB, Tamisier R, Pepin JL, Borel JC. Nasal obstruction and male gender contribute to the persistence of mouth opening during sleep in CPAP-treated obstructive sleep apnoea. Respirology 2015; 20:1123-30. [DOI: 10.1111/resp.12584] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 02/02/2015] [Accepted: 03/30/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Marius Lebret
- University Pierre and Marie Curie-Paris VI; Paris France
- AGIR à dom. Association; La Tronche France
| | - Nathalie Arnol
- AGIR à dom. Association; La Tronche France
- HP2 laboratory INSERM U1042; University Grenoble Alpes; Grenoble France
| | - Olivier Contal
- University of Health Sciences (HESAV); University of Applied Sciences and Arts of Western Switzerland (HES-SO); Lausanne Switzerland
| | | | - Renaud Tamisier
- HP2 laboratory INSERM U1042; University Grenoble Alpes; Grenoble France
- Department of Physiology and Sleep; Albert Michallon Hospital; Grenoble France
| | - Jean-Louis Pepin
- HP2 laboratory INSERM U1042; University Grenoble Alpes; Grenoble France
- Department of Physiology and Sleep; Albert Michallon Hospital; Grenoble France
| | - Jean-Christian Borel
- AGIR à dom. Association; La Tronche France
- HP2 laboratory INSERM U1042; University Grenoble Alpes; Grenoble France
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Shigemoto S, Shigeta Y, Nejima J, Ogawa T, Matsuka Y, Clark GT. Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea. J Prosthodont Res 2015; 59:161-71. [PMID: 25944119 DOI: 10.1016/j.jpor.2015.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 04/09/2015] [Accepted: 04/10/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE This review article covers the diagnosis and treatment of obstructive sleep apnea (OSA) from a dental perspective. It addresses the issue of when and how to screen for and then, if indicated, refer the patient for a more comprehensive. STUDY SELECTION Our focus in this article was on identifying current unanswered questions that relevant to OSA problems that dental scientists have to pursue and on providing valuable information on that problems, consequently the previous studies which investigated or reviewed the diagnosis and treatment of OSA were included. In addition, we included studies on jaw movements during sleep and on the use of a lateral cephalometric film related to the diagnosis and treatment of OSA. RESULTS The role of portable sleep monitoring devices versus full laboratory polysomnography is discussed. This review also describes what is known about the efficacy of mandibular advancement devices and when and how they fit in to a treatment program for a patient with obstructive sleep apnea. Finally some basic research is presented on jaw movements during sleep and how a lateral cephalometric film can be used to assess the changes of the airway with body posture and head posture. CONCLUSION This article provides the valuable suggestions for the clinical questions in the diagnosis and treatment of OSA.
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Affiliation(s)
- Shuji Shigemoto
- Department of Fixed Prosthodontics, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan; Department of Fixed Prosthodontics, School of Dental Medicine, Tsurumi University, Yokohama, Japan
| | - Yuko Shigeta
- Department of Fixed Prosthodontics, School of Dental Medicine, Tsurumi University, Yokohama, Japan.
| | - Jun Nejima
- Department of Internal Medicine, Tsurumi University School of Dental Medicine, Yokohama, Japan
| | - Takumi Ogawa
- Department of Fixed Prosthodontics, School of Dental Medicine, Tsurumi University, Yokohama, Japan
| | - Yoshizo Matsuka
- Department of Fixed Prosthodontics, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Glenn T Clark
- Orofacial Pain/Oral Medicine Center, Division of Diagnostic Sciences, Ostrow School of Dentistry, University of Southern California, Los Angeles, USA
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Martinot JB, Senny F, Denison S, Cuthbert V, Gueulette E, Guénard H, Pépin JL. Mandibular movements identify respiratory effort in pediatric obstructive sleep apnea. J Clin Sleep Med 2015; 11:567-74. [PMID: 25766710 DOI: 10.5664/jcsm.4706] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 01/19/2015] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea-hypopnea (OAH) diagnosis in children is based on the quantification of flow and respiratory effort (RE). Pulse transit time (PTT) is one validated tool to recognize RE. Pattern analysis of mandibular movements (MM) might be an alternative method to detect RE. We compared several patterns of MM to concomittant changes in PTT during OAH in children with adenotonsillar hypertrophy. METHODS PARTICIPANTS 33 consecutive children with snoring and symptoms/signs of OAH. MEASUREMENTS MMs were measured during polysomnography with a magnetometer device (Brizzy Nomics, Liege, Belgium) placed on the chin and forehead. Patterns of MM were evaluated representing peak to peak fluctuations > 0.3 mm in mandibular excursion (MML), mandibular opening (MMO), and sharp MM (MMS), which closed the mouth on cortical arousal (CAr). RESULTS The median (95% CI) hourly rate of at least 1 MM (MML, or MMO, or MMS) was 18.1 (13.2-36.3) and strongly correlated with OAHI (p = 0.003) but not with central apnea-hypopnea index (CAHI; p = 0.292). The durations when the MM amplitude was > 0.4 mm and PTT > 15 ms were strongly correlated (p < 0.001). The mean (SD) of MM peak to peak amplitude was larger during OAH than CAH (0.9 ± 0.7 mm and 0.2 ± 0.3 mm; p < 0.001, respectively). MMS at the termination of OAH had larger amplitude compared to MMS with CAH (1.5 ± 0.9 mm and 0.5 ± 0.7 mm, respectively, p < 0.001). CONCLUSIONS MM > 0.4 mm occurred frequently during periods of OAH and were frequently terminated by MMS corresponding to mouth closure on CAr. The MM findings strongly correlated with changes in PTT. MM analysis could be a simple and accurate promising tool for RE characterization and optimization of OAH diagnosis in children.
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Affiliation(s)
- Jean-Benoît Martinot
- Départements de Pneumologie et de Pédiatrie, Clinique et Maternité St Elisabeth, Namur, Belgium
| | | | - Stéphane Denison
- Départements de Pneumologie et de Pédiatrie, Clinique et Maternité St Elisabeth, Namur, Belgium
| | - Valérie Cuthbert
- Départements de Pneumologie et de Pédiatrie, Clinique et Maternité St Elisabeth, Namur, Belgium
| | - Emmanuelle Gueulette
- Départements de Pneumologie et de Pédiatrie, Clinique et Maternité St Elisabeth, Namur, Belgium
| | - Hervé Guénard
- Laboratoire de Physiologie et CHU de Bordeaux, France
| | - Jean-Louis Pépin
- Université Grenoble Alpes, HP2; Inserm U1042, Grenoble, France. CHU de Grenoble, Laboratoire EFCR, Secteur Physiologie Sommeil et Exercice, Pole THORAX et VAISSEAUX Grenoble, France
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Maury G, Senny F, Cambron L, Albert A, Seidel L, Poirrier R. Mandible behaviour interpretation during wakefulness, sleep and sleep-disordered breathing. J Sleep Res 2014; 23:709-716. [PMID: 25078069 DOI: 10.1111/jsr.12180] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 05/15/2014] [Indexed: 11/30/2022]
Abstract
The mandible movement (MM) signal provides information on mandible activity. It can be read visually to assess sleep-wake state and respiratory events. This study aimed to assess (1) the training of independent scorers to recognize the signal specificities; (2) intrascorer reproducibility and (3) interscorer variability. MM was collected in the mid-sagittal plane of the face of 40 patients. The typical MM was extracted and classified into seven distinct pattern classes: active wakefulness (AW), quiet wakefulness or quiet sleep (QW/S), sleep snoring (SS), sleep obstructive events (OAH), sleep mixed apnea (MA), respiratory related arousal (RERA) and sleep central events (CAH). Four scorers were trained; their diagnostic capacities were assessed on two reading sessions. The intra- and interscorer agreements were assessed using Cohen's κ. Intrascorer reproducibility for the two sessions ranged from 0.68 [95% confidence interval (CI): 0.59-0.77] to 0.88 (95% CI: 0.82-0.94), while the between-scorer agreement amounted to 0.68 (95% CI: 0.65-0.71) and 0.74 (95% CI: 0.72-0.77), respectively. The overall accuracy of the scorers was 75.2% (range: 72.4-80.7%). CAH MMs were the most difficult to discern (overall accuracy 65.6%). For the two sessions, the recognition rate of abnormal respiratory events (OAH, CAH, MA and RERA) was excellent: the interscorer mean agreement was 90.7% (Cohen's κ: 0.83; 95% CI: 0.79-0.88). The discrimination of OAH, CAH, MA characteristics was good, with an interscorer agreement of 80.8% (Cohen's κ: 0.65; 95% CI: 0.62-0.68). Visual analysis of isolated MMs can successfully diagnose sleep-wake state, normal and abnormal respiration and recognize the presence of respiratory effort.
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Affiliation(s)
- Gisèle Maury
- Service de pneumologie, Université catholique de Louvain, CHU Dinant Godinne, Yvoir, Belgium
| | - Frédéric Senny
- Montefiore Department for Microsystems and HELMO Gramme, University of Liège, Liège, Belgium
| | - Laurent Cambron
- Sleep/Wake Center of the University Hospital of Liège, University of Liège, Liège, Belgium
| | - Adelin Albert
- Medical Informatics and Biostatistics, Laboratory, University of Liège, Liège, Belgium
| | - Laurence Seidel
- Medical Informatics and Biostatistics, Laboratory, University of Liège, Liège, Belgium
| | - Robert Poirrier
- Sleep/Wake Center of the University Hospital of Liège, University of Liège, Liège, Belgium
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Kato T, Katase T, Yamashita S, Sugita H, Muraki H, Mikami A, Okura M, Ohi M, Masuda Y, Taniguchi M. Responsiveness of jaw motor activation to arousals during sleep in patients with obstructive sleep apnea syndrome. J Clin Sleep Med 2013; 9:759-65. [PMID: 23946705 DOI: 10.5664/jcsm.2914] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES We aimed to characterize the association between jaw muscle contractions and respiratory events in patients with obstructive sleep apnea syndrome (OSAS) and to investigate the responsiveness of the contractions to respiratory events in comparison with that of leg muscles in terms of arousal types and sleep states. METHODS Polysomnographic (PSG) recordings were performed in 19 OSAS patients (F/M: 2/17; 53.1 ± 13.7 years; AHI: 31.8 ± 19.9/h) with no concomitant sleep bruxism or other sleep-related movement disorders. Muscle contractions of unilateral masseter (MAS) and anterior tibialis (AT) muscles were scored during sleep in association with graded arousals (microarousals and awakenings) related or unrelated to apneahypopnea events. RESULTS Arousals were scored for 68.2% and 52.3% of respiratory events during light NREM and REM sleep, respectively. Respiratory events with arousals were associated with longer event duration and/or larger transient oxygen desaturation than those without (ANOVAs: p < 0.05). Median response rates of MAS events to respiratory events were 32.1% and 18.9% during NREM and REM sleep. During two sleep states, MAS muscle was rarely activated after respiratory events without arousals, while its response rate increased significantly in association with the duration of arousals (Friedman tests: p < 0.001). A similar response pattern was found for AT muscle. Motor responsiveness of the two muscles to arousals after respiratory events did not differ from responsiveness to spontaneous arousals in two sleep stages. CONCLUSION In patients with OSAS, the contractions of MAS and AT muscles after respiratory events can be nonspecific motor phenomena, dependent on the duration of arousals rather than the occurrence of respiratory events.
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Affiliation(s)
- Takafumi Kato
- Osaka University Graduate School of Dentistry, Department of Oral Anatomy and Neurobiology, Suita, Japan.
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Asynchronies and sleep disruption in neuromuscular patients under home noninvasive ventilation. Respir Med 2012; 106:1478-85. [DOI: 10.1016/j.rmed.2012.05.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 05/24/2012] [Accepted: 05/30/2012] [Indexed: 12/22/2022]
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Maury G, Cambron L, Jamart J, Marchand E, Senny F, Poirrier R. Added value of a mandible movement automated analysis in the screening of obstructive sleep apnea. J Sleep Res 2012; 22:96-103. [PMID: 22835145 DOI: 10.1111/j.1365-2869.2012.01035.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In-laboratory polysomnography is the 'gold standard' for diagnosing obstructive sleep apnea syndrome, but is time consuming and costly, with long waiting lists in many sleep laboratories. Therefore, the search for alternative methods to detect respiratory events is growing. In this prospective study, we compared attended polysomnography with two other methods, with or without mandible movement automated analysis provided by a distance-meter and added to airflow and oxygen saturation analysis for the detection of respiratory events. The mandible movement automated analysis allows for the detection of salient mandible movement, which is a surrogate for arousal. All parameters were recorded simultaneously in 570 consecutive patients (M/F: 381/189; age: 50±14 years; body mass index: 29±7 kg m(-2) ) visiting a sleep laboratory. The most frequent main diagnoses were: obstructive sleep apnea (344; 60%); insomnia/anxiety/depression (75; 13%); and upper airway resistance syndrome (25; 4%). The correlation between polysomnography and the method with mandible movement automated analysis was excellent (r: 0.95; P<0.001). Accuracy characteristics of the methods showed a statistical improvement in sensitivity and negative predictive value with the addition of mandible movement automated analysis. This was true for different diagnostic thresholds of obstructive sleep severity, with an excellent efficiency for moderate to severe index (apnea-hypopnea index ≥15h(-1) ). A Bland & Altman plot corroborated the analysis. The addition of mandible movement automated analysis significantly improves the respiratory index calculation accuracy compared with an airflow and oxygen saturation analysis. This is an attractive method for the screening of obstructive sleep apnea syndrome, increasing the ability to detect hypopnea thanks to the salient mandible movement as a marker of arousals.
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Affiliation(s)
- Gisele Maury
- Department of Pneumology, CHU Mont Godinne, Université catholique de Louvain, Yvoir, Belgium.
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Short-term change in occlusal function after using mandibular advancement appliance for snoring: a pilot study. SLEEP DISORDERS 2012; 2012:652154. [PMID: 23470851 PMCID: PMC3581265 DOI: 10.1155/2012/652154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 02/06/2012] [Indexed: 11/17/2022]
Abstract
The main aim was to evaluate the influence on occlusal contact area (OCA), maximum bite force (MBF), center of occlusal load (COL), and tooth pain after the nocturnal use of different mandibular advance appliances (MAAs) for snoring. Subjects were consisted of ten adult volunteers with mild snoring in Hiroshima University Hospital. Recordings of occlusal function were performed six times for two hours, that is, immediately and 5, 15, 30, 60, and 120 minutes after the nocturnal use of MAA. The subjects continuously scored their pain intensity on a 10 cm visual analogue scale (VAS) when MBF was measured. Comparing two MAAs, OCA and MBF were significantly larger in two-piece MAA than in one-piece MAA five minutes after removing the appliance. Significant difference in COL and VAS score compared to baseline disappeared more quickly with two-piece MAA than with one-piece MAA. In conclusion, it is shown that two-piece MAA could be superior to the one-piece one in terms of the degree side effect on occlusal function.
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Cheliout-Heraut F, Senny F, Djouadi F, Ouayoun M, Bour F. Obstructive sleep apnoea syndrome: comparison between polysomnography and portable sleep monitoring based on jaw recordings. Neurophysiol Clin 2011; 41:191-8. [PMID: 22078731 DOI: 10.1016/j.neucli.2011.09.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 09/14/2011] [Accepted: 09/14/2011] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Obstructive sleep apnoea syndrome (OSAS) constitutes a new major public health problem because of its several pathophysiologic consequences such as cognitive disorders, excessive daytime sleepiness with risks of traffic accidents, cardiovascular implications, and decrease of quality of life. The necessity of a gold-standard polysomnography to ensure an accurate diagnosis implies an expensive, technical and time-consuming examination. Thus, it seems logical to develop new systems so as to diagnose SAS and to make it possible to detect apnoeas/hypopnoeas easily during sleep even at home. AIM OF THE STUDY To assess a novel type-3 portable monitoring (PM) device, the Somnolter, and dedicated automatic analysis of several signals, one of which is the mandibular movement signal. METHOD We studied patients suffering from OSAS. For all the patients, a nocturnal diagnosis polysomnography (PSG) was recorded in hospital settings, based on six EEG channels, two EOG channels, chin EMG channel, EKG, and respiratory parameters. At the same time, the Somnolter PM device recorded the physiological parameters from its own nasal prongs, thoracic belt, pulse oxymeter, body position, and jaw movement sensors. A visual analysis of PSG recordings was made leading to the detection of apnoea/hypopnoea index (AHI-PSG) and an automatic analysis of the Somnolter traces was performed to get automatic apnoea/hypopnoea index (AHI-A). The added value of the mandible movement signals was the particular jaw movements related to arousals, to respiratory efforts and to sleep/wake state. A comparison was made between the automatic and gold AHIs standard and the correlation was calculated between them. RESULTS Ninety patients, aged between 47 and 70 years (mean age: 55.4±8.7) took part in the study. The linear regression and the correlation coefficient between AHI-PSG and AHI-A showed the good reliability of the automatic method. The Bland Altman analysis shows a correlation of 0.95 with a sensitivity of 83.6 and specificity of 81.8. CONCLUSION The dedicated automatic analysis based on mandibular movements presents a good potential for the diagnosis of OSAS. The AHI computed by the automatic method is correlated with the AHI-PSG and the Somnolter could easily be used both in hospital, and in ambulatory settings.
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Affiliation(s)
- F Cheliout-Heraut
- Physiology department, Versailles-Saint-Quentin University, Garches hospital, Garches, France.
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28
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The sleep/wake state scoring from mandible movement signal. Sleep Breath 2011; 16:535-42. [PMID: 21660653 DOI: 10.1007/s11325-011-0539-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 05/26/2011] [Accepted: 05/31/2011] [Indexed: 10/18/2022]
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NIKOLOPOULOU M, NAEIJE M, AARAB G, HAMBURGER HL, VISSCHER CM, LOBBEZOO F. The effect of raising the bite without mandibular protrusion on obstructive sleep apnoea. J Oral Rehabil 2011; 38:643-7. [DOI: 10.1111/j.1365-2842.2011.02221.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ayuse T, Ayuse T, Ishitobi S, Yoshida H, Nogami T, Kurata S, Hoshino Y, Oi K. The mandible advancement may alter the coordination between breathing and the non-nutritive swallowing reflex. J Oral Rehabil 2010; 37:336-45. [PMID: 20337868 DOI: 10.1111/j.1365-2842.2010.02067.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The coordination between nasal breathing and non-nutritive swallowing serves as a protective reflex against potentially asphyxiating material, i.e. saliva and secretions, entering the respiratory tract. Although this protective reflex is influenced by positional changes in the head and body, the effect of mandible position on this reflex is not fully understood. We examined the effect of mandible advancement associated with mouth opening on the coordination between nasal breathing and non-nutritive swallowing induced by continuous infusion of distilled water into the pharyngeal cavity. The combination of mandible advancement and mouth opening increased the duration of swallowing apnoea and submental electromyographic burst duration. When the mandible was advanced with the mouth open, the duration of swallowing apnoea increased significantly compared with the centric position (0.79 +/- 0.23 vs. 0.64 +/- 0.12 s, P < 0.05, n = 12), and the duration of submental electromyographic activity increased significantly (2.11 +/- 0.63 vs. 1.46 +/- 0.25 s, P < 0.05, n = 12). Mandible advancement with mouth opening altered the respiratory phase resetting during swallowing and the timing of swallow in relation to respiratory cycle phase. We conclude that mandible re-positioning may strongly influence the coordination between nasal breathing and non-nutritive swallowing by altering respiratory parameters and by inhibiting movement of the tongue-jaw complex.
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Affiliation(s)
- T Ayuse
- Department of Special Care Dentistry, Nagasaki University Hospital, Nagasaki, Japan
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Effects of an oral appliance with different mandibular protrusion positions at a constant vertical dimension on obstructive sleep apnea. Clin Oral Investig 2009; 14:339-45. [PMID: 19536571 DOI: 10.1007/s00784-009-0298-9] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 06/02/2009] [Indexed: 10/20/2022]
Abstract
The aim of the study was to assess the influence of four mandibular protrusion positions, at a constant vertical dimension, on obstructive sleep apnea (OSA). Seventeen OSA patients (49.2 +/- 8.5 years) received an adjustable mandibular advancement device (MAD). The patients underwent four polysomnographic recordings with their MAD in situ at, in random order, 0%, 25%, 50%, and 75% of the maximum protrusion. The mean apnea-hypopnea index (AHI) values of the patients differed significantly between the protrusion positions (P < 0.000). The 25% protrusion position resulted in a significant reduction of the AHI with respect to the 0% position, while in the 50% and 75% positions, even lower AHI values were found. The number of side effects was larger starting at the 50% protrusion position. We therefore recommend coming to a weighted compromise between efficacy and side effects by starting a MAD treatment in the 50% protrusion position.
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Lavigne GJ, Khoury S, Abe S, Yamaguchi T, Raphael K. Bruxism physiology and pathology: an overview for clinicians. J Oral Rehabil 2009; 35:476-94. [PMID: 18557915 DOI: 10.1111/j.1365-2842.2008.01881.x] [Citation(s) in RCA: 427] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Awake bruxism is defined as the awareness of jaw clenching. Its prevalence is reported to be 20% among the adult population. Awake bruxism is mainly associated with nervous tic and reactions to stress. The physiology and pathology of awake bruxism is unknown, although stress and anxiety are considered to be risk factors. During sleep, awareness of tooth grinding (as noted by sleep partner or family members) is reported by 8% of the population. Sleep bruxism is a behaviour that was recently classified as a 'sleep-related movement disorder'. There is limited evidence to support the role of occlusal factors in the aetiology of sleep bruxism. Recent publications suggest that sleep bruxism is secondary to sleep-related micro-arousals (defined by a rise in autonomic cardiac and respiratory activity that tends to be repeated 8-14 times per hour of sleep). The putative roles of hereditary (genetic) factors and of upper airway resistance in the genesis of rhythmic masticatory muscle activity and of sleep bruxism are under investigation. Moreover, rhythmic masticatory muscle activity in sleep bruxism peaks in the minutes before rapid eye movement sleep, which suggests that some mechanism related to sleep stage transitions exerts an influence on the motor neurons that facilitate the onset of sleep bruxism. Finally, it remains to be clarified when bruxism, as a behaviour found in an otherwise healthy population, becomes a disorder, i.e. associated with consequences (e.g. tooth damage, pain and social/marital conflict) requires intervention by a clinician.
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Affiliation(s)
- G J Lavigne
- Faculty of Dentistry, Surgery Department, Pain, Sleep and Trauma Unit, Université de Montréal, Hôpital du Sacré-Coeur de Montréal, Montréal, Canada.
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Svensson M, Franklin KA, Theorell-Haglöw J, Lindberg E. Daytime sleepiness relates to snoring independent of the apnea-hypopnea index in women from the general population. Chest 2008; 134:919-924. [PMID: 18753465 DOI: 10.1378/chest.08-0847] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES The aim was to investigate the significance of snoring and sleep apnea on daytime symptoms in a population-based sample of women. METHOD From the general population, 400 women aged 20 to 70 years were randomly selected, with oversampling of habitually snoring women. The women were investigated using full-night polysomnography and a questionnaire. The apnea-hypopnea index (AHI) was calculated, and women who acknowledged snoring loudly and disturbingly often or very often were considered habitual snorers. RESULTS Habitual snoring was independently related to excessive daytime sleepiness (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.31 to 3.99), to falling asleep involuntarily during the day (OR, 2.11; 95% CI, 1.06 to 4.21), to waking up unrefreshed (OR, 2.14; 95% CI, 1.30 to 3.52), to daytime fatigue (OR, 2.77; 95% CI, 1.54 to 4.99), and to a dry mouth on awakening (OR, 2.00; 95% CI, 1.22 to 3.27) after adjustment for AHI, age, body mass index (BMI), smoking, total sleep time, percentage of slow-wave sleep, and percentage of rapid eye movement (REM) sleep. An AHI > or = 15/h was only related to a dry mouth on awakening after adjustment for snoring, age, BMI, smoking, total sleep time, percentage of slow-wave sleep, and percentage of REM sleep (OR, 2.24; 95% CI, 1.14 to 4.40). An AHI of 5 to 15/h was not related to any daytime symptom. CONCLUSIONS Excessive daytime sleepiness and daytime fatigue are related to habitual snoring independent of the apnea-hypopnea frequency, age, obesity, smoking, and sleep parameters in a population-based sample of women, but not to the AHI. This indicates that snoring is an independent cause of excess daytime sleepiness and not merely a proxy for sleep apnea.
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Affiliation(s)
- Malin Svensson
- Department of Surgical Sciences, Otorhinolaryngology, Head and Neck Surgery, Uppsala University, Uppsala.
| | - Karl A Franklin
- Department of Respiratory Medicine, University Hospital, Umeå, Sweden
| | - Jenny Theorell-Haglöw
- Department of Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, Uppsala
| | - Eva Lindberg
- Department of Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, Uppsala
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Senny F, Destine J, Poirrier R. Midsagittal Jaw Movement Analysis for the Scoring of Sleep Apneas and Hypopneas. IEEE Trans Biomed Eng 2008; 55:87-95. [DOI: 10.1109/tbme.2007.899351] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Isono S. Optimal combination of head, mandible and body positions for pharyngeal airway maintenance during perioperative period: lesson from pharyngeal closing pressures. ACTA ACUST UNITED AC 2007. [DOI: 10.1053/j.sane.2007.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Neck extension because of contraction of cervical extensor muscles often brings about a lower-positioned tongue secondary to jaw opening in patients with congenital myopathy (CM). We hypothesized that neck extension in control subjects would reproduce the lower position of the tongue similar to that found in a CM patient. A simple method was formulated to evaluate the tongue position in terms of tongue pressure on the maxillary molar. A pair of pressure sensors was attached to the buccal and lingual surfaces of the upper molar for both the CM patient and four control subjects. Changes in the buccal and tongue pressures were recorded at the neck extension position for the CM patient and during both the natural head position and neck extension for the control subjects. There was a remarkable difference between buccal and tongue pressures in the neck extension position in the CM patient: tongue pressure was not detected at all, indicating there was no contact between tongue and upper molar. The buccal and tongue pressures were approximately equal in the natural head position in the control subjects. However, both buccal and tongue pressures were reduced during neck extension in the control subjects, with a greater decrease in the tongue pressure than the buccal pressure. These findings suggest that neck extension in a control subject reproduces the lower position of the tongue observed in CM patients. We propose that the pressure sensor enables evaluation of the tongue position, but further investigation is required.
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Affiliation(s)
- S Tsuiki
- Japan Foundation for Neuroscience and Mental Health, Tokyo, Japan.
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Verma M, Seto-Poon M, Wheatley JR, Amis TC, Kirkness JP. Influence of breathing route on upper airway lining liquid surface tension in humans. J Physiol 2006; 574:859-66. [PMID: 16690717 PMCID: PMC1817732 DOI: 10.1113/jphysiol.2005.102129] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
We have recently demonstrated that the severity of sleep-disordered breathing in obstructive sleep apnoea hypopnoea syndrome (OSAHS) can be reduced by lowering the surface tension (gamma) of the upper airway lining liquid (UAL). Morning xerostomia (related to oral breathing during sleep) is reported by most OSAHS patients. In the present study we examine relationships between breathing route, oral mucosal 'wetness' and the gamma of UAL. We studied eight healthy subjects (age, 25 +/- 5 years [mean +/- S.D.]; body-mass index, 23 +/- 2 kg m(-2)) during a 120 min challenge of both nasal-only breathing (mouth taped) and oral-only breathing (nose clip), each on a separate day (randomized). Both oral mucosal 'wetness' (5 s contact gravimetric absorbent paper strip method) and the gamma ('pull-off' force technique) of 0.2 microl samples of UAL obtained from the posterior pharyngeal wall were measured at 15 min intervals (mouth tape removed and replaced as required). Upper airway mucosal 'wetness' increased during 120 min of nasal breathing from 4.0 +/- 0.4 (mean +/- S.E.M.) to 5.3 +/- 0.3 microl (5 s)(-1) but decreased from 4.5 +/- 0.4 to 0.1 +/- 0.2 microl (5 s)(-1) with oral breathing (both P < 0.001, repeated-measures ANOVA, Tukey's multiple comparison test, post hoc test). Concurrently, the gamma of UAL decreased from 59.3 +/- 2.2 to 51.8 +/- 0.98 mN m(-1) with nasal breathing but increased from 64.4 +/- 2.7 to 77.4 +/- 1.1 mN m(-1) with oral breathing (P < 0.001). For the group and all conditions studied, gamma of UAL values strongly correlated with upper airway mucosal 'wetness' (correlation coefficient, r2 = -0.34, P < 0.001; linear regression). We conclude that oral breathing increases and nasal breathing decreases the gamma of UAL in healthy subjects during wakefulness. We speculate that nasal breathing in OSAHS patients during sleep may promote a low gamma of UAL that may contribute to reducing the severity of sleep-disordered breathing.
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Affiliation(s)
- Manisha Verma
- Ludwig Engel Centre for Respiratory Research, Westmead Hospital, Westmead, NSW 2145, Australia
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Uzun L, Ugur MB, Altunkaya H, Ozer Y, Ozkocak I, Demirel CB. Effectiveness of the jaw-thrust maneuver in opening the airway: a flexible fiberoptic endoscopic study. ORL J Otorhinolaryngol Relat Spec 2005; 67:39-44. [PMID: 15753621 DOI: 10.1159/000084304] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2004] [Accepted: 07/01/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVE A prospective study was carried out to find the exact site of obstruction in sleep model and to quantitatively evaluate the effect of Jaw-thrust maneuver (JTM) in opening the obstructed airway using flexible fiberoptic endoscope. METHODS Twenty-eight ASA physical status I or II patients with snoring symptom undergoing elective surgery were included. The patients were held in supine position without hyperextension of the neck. Having induced anesthesia, the base of the tongue and laryngeal inlet and/or epiglottis were visualized using endoscope. The patients' epiglottides were classified as leaf-shaped, curved (concaved or omega-shaped) and floppy types. We graded the airway opening at the level of epiglottis into six grades and obstruction at the tongue base level into four grades. The grades during inspiration (GrIns), expiration (GrExp) and after JTM (GrJTM) were recorded and compared with Pearson chi-square test. RESULTS The strictly curved (Omega-shaped or concaved) epiglottis supplied a salvage pathway for airflow that resisted collapsing with the posterior movement of the tongue base in 2 patients. When we compared GrIns with GrExp for epiglottis the difference was statistically significant (chi(2) = 0.001), but the difference for tongue base was not (chi(2) = 0.152). After JTM, GrJTM for both epiglottis and tongue base were significantly better than GrIns and GrExp (chi(2) < 0.001). CONCLUSION Tongue base was the principal site of obstruction although during the respiratory cycle the position of epiglottis changed prominently and increased the obstruction in inspiration. JTM alone significantly relieved the obstruction at the tongue base and epiglottis levels and increased the retroglossal airway.
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Affiliation(s)
- Lokman Uzun
- Karaelmas University, School of Medicine, Department of Otorhinolaryngology, Head and Neck Surgery, Zonguldak, Turkey.
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Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA. Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliances. Sleep Med Rev 2005; 8:443-57. [PMID: 15556377 DOI: 10.1016/j.smrv.2004.04.002] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Snoring and obstructive sleep apnea form part of a spectrum of sleep disordered breathing affecting a significant proportion of the general population and particularly the middle aged. The consequences can be severe and even life threatening for both the individual directly affected and those more remotely involved. Adverse sequelae can manifest themselves acutely or in the longer term as a result of obstructive breathing induced hypersomnolence, neurocognitive deficits and cardiovascular abnormalities. The combination of anatomical and neuromuscular risk factors in the pathogenesis of OSA has resulted in a varied approach to its management. One such treatment option is mandibular repositioning appliances (MRA), which mechanically stabilize the airway. Whilst the efficacy of this simple intervention has been rigorously proven quite recently in a significant proportion of patients with varying disease severity, individual patient selection in its application remains uncertain. Short-term side-effects are common but usually transient, whilst in the long-term minor permanent adverse developments on the dentition and occlusion have been reported. Considering both the medicolegal implications of snoring and OSA and the increasing popularity of MRA, it is recommended that skilled multidisciplinary respiratory and dental personnel form the primary care team.
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Affiliation(s)
- Peter A Cistulli
- Department of Respiratory and Sleep Medicine, St George Hospital, University of New South Wales, Kogarah, Sydney, NSW 2217, Australia.
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Dispositivos de avance mandibular (DAM) en el tratamiento del SAHS. Arch Bronconeumol 2005. [DOI: 10.1016/s0300-2896(05)70755-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Gao X, Otsuka R, Ono T, Honda EI, Sasaki T, Kuroda T. Effect of titrated mandibular advancement and jaw opening on the upper airway in nonapneic men: a magnetic resonance imaging and cephalometric study. Am J Orthod Dentofacial Orthop 2004; 125:191-9. [PMID: 14765057 DOI: 10.1016/s0889-5406(03)00508-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to examine adaptive changes in the cross-sectional area of the upper airway during mandibular advancement and jaw opening and to explore whether these changes are directly related to morphologic features of the mandible. Fourteen nonapneic men participated in this study. A custom-made oral device was used to keep the mandible at 0% (F(0)V(0)), 50% (F(50)V(0)), 75% (F(75)V(0)), or 100% (F(100)V(0)) of maximum advancement, and at 50% (F(75)V(50)), 75% (F(75)V(75)), or 100% (F(75)V(100)) of maximum gape at F(75)V(0). Magnetic resonance imaging was used to investigate differences in the upper-airway cross-sectional area in these 7 positions. To eliminate excessive individual variation, changes in the mean (mean%) and minimum (min%) cross-sectional area of the upper airway were calculated as percentages of those at F(0)V(0). Cephalograms were taken to analyze morphologic features of the mandible. A dose-dependent change was seen when the mandible was advanced. The min% in F(100)V(0) was significantly greater than those in F(50)V(0) and F(75)V(0). The change in the upper airway size varied between subjects during jaw opening. At F(75)V(0), the min% of the whole upper airway was significantly associated with morphologic features of the mandible, such as the mandibular plane angle and lengths of the mandibular body and ramus.
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Affiliation(s)
- Xuemei Gao
- Department of Orthodontics, School of Stomatology, Peking University, Beijing, China
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Abstract
OBJECTIVE Obstructive sleep apnea (OSA) is far more common in males than females. The discrepancy between the lower prevalence of OSA, the greater frequency of obesity and the smaller airway size in women compared to men suggests that a gender difference underlies this condition. We hypothesized that due to differences in tissue linkage women have more stable and less mobile upper airway structures than men, providing protection against severe forms of OSA. METHODS Seventy-one consecutive patients with OSA, defined as having apnea-hypopnea index > or =5 events per hour, were enrolled into the study. The median (range) apnea-hypopnea index was 20 (5-132) events/h. In addition, measurements of upper airway dimensions were made, using an acoustic reflectance method, while the lower jaw was in the resting position and during retrusive posture. Measurements of upper airway dimensions were used during wakefulness to examine whether changes in pharyngeal dimensions, resulting from retrusive movement of the mandible commonly occurring during sleep, would explain the gender differences in the characteristics of OSA. RESULTS OSA was much more positional and severe in men than women as indicated by the higher apnea-hypopnea index in supine position compared with sleeping on the side (difference between supine and side apnea-hypopnea index: 43.7+/-5.2 (SEM) events/h in men versus 10.7+/-7.6 events/h in women, P=0.0015). The position dependency of OSA was most pronounced in those patients who demonstrated the largest decrease in pharyngeal cross-sectional area with retrusive movement of the mandible. There was no significant change in pharyngeal cross-sectional area as a result of retrusive movement of the mandible in women. CONCLUSIONS Men tend to have a larger but more collapsible airway during mandibular movement than women and this, in part, may play a role in the positional dependency and severity of OSA in men.
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Affiliation(s)
- Vahid Mohsenin
- Yale Center for Sleep Medicine, Yale University School of Medicine, John B. Pierce Laboratory, 290 Congress Avenue, New Haven, CT 06519, USA.
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Abstract
BACKGROUND Sleep-related breathing disorders are common and often are associated with vascular complications such as arterial hypertension, coronary heart disease and stroke. The most widely studied form of these disorders is obstructive sleep apnea. Patients usually are diagnosed with obstructive sleep apnea years after the onset of symptoms, which generally are nonspecific and include excessive daytime sleepiness, chronic fatigue and habitual snoring. The risk factors for sleep apnea are obesity, advancing age, male sex and maxillofacial abnormalities. This review focuses on the diagnosis and treatment of obstructive sleep apnea and, specifically, on the utility of oral appliances in the management of this disorder. METHODS The review is based on a MEDLINE search for articles in English on this topic. The article discusses results of randomized studies and prospective case series. CLINICAL IMPLICATIONS Several treatment options are quite effective. Nasal continuous positive airway pressure, with an overall acceptance rate of 70 percent, is the most widely used treatment modality. Maxillofacial surgery, although effective, is reserved for patients who have not responded to the more conventional therapies. Newer methods include application of oral appliances. Oral appliances have been shown to alleviate the severity of respiratory disturbances during sleep by about 60 percent, with an overall acceptance rate of 75 percent. The long-term complications generally are minor and are related to occlusal changes and temporomandibular joint discomfort. CONCLUSIONS With the advent of oral appliances, dentists are increasingly involved in managing the care of patients with sleep-related breathing disorders. Further studies are needed to determine the long-term complications of this type of intervention for the treatment of sleep-related breathing disorders.
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Schmidt-Nowara W. Recent Developments in Oral Appliance Therapy of Sleep Disordered Breathing. Sleep Breath 2002; 3:103-106. [PMID: 11898115 DOI: 10.1007/s11325-999-0103-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Oral appliances are increasingly gaining a place in the treatment of sleep disordered breathing caused by upper airway obstruction. This review of publications since 1995 documents substantial progress in the scientific basis for this therapy. Imaging by several techniques has shown that mandibular advancing oral appliances open the airway in awake and anaesthetized subjects, creating the presumption that this effect is maintained in sleep. Three controlled cross-over treatment trials have shown that patients consistently prefer oral appliance over continuous positive airway pressure therapy, especially when the treatment effect is strong. Appliance design and use indicates a preference for adjustable mandibular advancing appliances. Complications of therapy appear to be infrequent, but evidence for safety of long-term use is still limited. Oral appliance therapy can be an effective therapy for sleep disorders caused by upper airway obstruction. Considering the accumulated evidence, it is no longer tenable to label oral appliance therapy an OexperimentalO procedure.
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Liu Y, Park YC, Lowe AA, Fleetham JA. Supine Cephalometric Analyses of an Adjustable Oral Appliance Used in the Treatment of Obstructive Sleep Apnea. Sleep Breath 2002; 4:59-66. [PMID: 11868121 DOI: 10.1007/bf03045025] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE: To investigate the effects of the Klearway(TM) appliance on the upper airway in patients with obstructive sleep apnea (OSA) in the supine position. METHODS: Sixteen subjects (12 males and 4 females) were recruited on the basis of baseline polysomnography with a documented Apnea and Hypopnea Index (AHI) >15 per hour. A second overnight sleep study was performed for each subject with the appliance in place. Baseline supine cephalometry was performed for each subject before the initial insertion of the appliance, and follow-up supine cephalometry was undertaken with the appliance in place. RESULTS: The polysomnographic variables improved significantly, and the mean changes in overbite and overjet were 5.15 mm and 6.26 mm after insertion of the Klearway(TM) appliance. The supine sagittal cross-sectional areas of the pharynx and the tongue significantly increased, while the linear distance from the hyoid position to the mandibular plane or the RGN-C3 line significantly decreased after insertion of the appliance. The ratio of the vertical pharyngeal length to the sagittal cross-sectional area of nasopharynx or tongue decreased significantly. When the subjects were evaluated on the basis of the after-insertion AHI, the group with good response (n = 11) was found to be significantly younger than the group with the poor response (n = 5). Similarly, the good responders revealed less prominent chins, larger tongue heights, and an increase in hypopharyngeal sagittal cross-sectional area after insertion of the appliance. There was a significant correlation between the improvement in AHI (%) and the supine middle airway space (r = -0.52, p < 0.05). CONCLUSION: The mechanical effect of the Klearway(TM) appliance on the upper airway and the stabilization of jaw posture may be important determinants of the efficacy of the appliance.
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Affiliation(s)
- Yuehua Liu
- Department of Oral Health Sciences Faculty of Dentistry; The University of British Columbia Vancouver, Canada
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Sherring D, Vowles N, Antic R, Krishnan S, Goss AN. Obstructive sleep apnoea: a review of the orofacial implications. Aust Dent J 2001; 46:154-65. [PMID: 11695153 DOI: 10.1111/j.1834-7819.2001.tb00276.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Obstructive sleep apnoea is a complex multifactorial condition produced by a combination of anatomical and physiological factors. There is a significant associated mortality and morbidity to obstructive sleep apnoea. There is an at least 25 per cent increased mortality from cardiovascular disease when obstructive sleep apnoea patients are compared to age and gender matched healthy people. Obstructive sleep apnoea sufferers also have a much higher industrial and motor vehicle accident rate. Management of the condition should be undertaken by a multidisciplinary team including respiratory physicians, sleep laboratory technicians, otorhinolaryngologists, oral and maxillofacial surgeons and dental specialists. The diagnostic and therapeutic interactions of team members are the key to successful treatment. The treatment regime utilises nasal continuous positive airway pressure devices, mandibular advancement splints and soft and hard tissue surgery. This review provides the dental practitioner with an introduction to obstructive sleep apnoea with particular emphasis on the orofacial aspects.
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Affiliation(s)
- D Sherring
- Oral and Maxillofacial Surgery Unit, Adelaide University
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